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Implantation of the Syncardia Total Artificial Heart
Published on: July 18, 2014
Prior Sternotomy and Ventricular Assist Device Implantation Do Not Adversely Impact Survival or Allograft Function
Ann C Gaffey1, Emily C Phillips1, Jessica Howard1
1Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Insights
Left ventricular assist device (LVAD) implantation or prior sternotomy before heart transplantation does not compromise outcomes. These strategies do not adversely affect graft function, hospital stay, or long-term survival after orthotopic heart transplantation (OHT).
Area of Science:
- Cardiology
- Cardiac Surgery
- Transplantation Medicine
Background:
- Orthotopic heart transplantation (OHT) is the gold standard for end-stage heart failure, but donor organ scarcity necessitates alternative strategies.
- Left ventricular assist devices (LVADs) are used as a bridge to transplantation, and a growing number of patients have undergone prior sternotomy.
- Reoperative sternotomy and LVAD explantation before OHT raise concerns about increased operative complexity and compromised patient outcomes.
Purpose of the Study:
- To evaluate the impact of LVAD implantation as a bridge to transplantation or prior sternotomy on perioperative, short-term, and long-term outcomes following OHT.
- To determine if increased technical difficulty associated with LVAD explantation or redo sternotomy compromises survival after OHT.
Main Methods:
- A retrospective analysis of 253 OHT patients from 2008-2013 was conducted.
- Patients were categorized into three groups: bridge to transplantation LVAD (n=72), prior sternotomy (n=65), and OHT with a virgin chest (n=116).
- Preoperative, intraoperative, and postoperative variables, along with short- and long-term survival (minimum 6-month follow-up), were analyzed.
Main Results:
- Cardiopulmonary bypass time was significantly longer in the LVAD and prior sternotomy groups compared to the virgin chest cohort.
- Both LVAD and prior sternotomy groups required higher blood transfusion volumes.
- While time to extubation and ICU length of stay were longer in the LVAD and prior sternotomy groups, there were no significant differences in overall hospital length of stay or short- and long-term survival among the three groups.
Conclusions:
- LVAD implantation as a bridge to transplantation or prior sternotomy does not negatively impact allograft function, hospital length of stay, or long-term survival after OHT.
- The decision-making process for managing patients awaiting transplantation should not be deterred by concerns regarding subsequent outcomes after OHT.
- These findings support the use of LVADs and proceeding with OHT after prior sternotomy, even with increased complexity.
Background:
Orthotopic heart transplantation (OHT) remains the gold standard for end-stage heart failure. However, donor availability is severely limited. With a median wait time of 6.6 months and more than 12% of patients waiting 5 or more years, the decision is often made to implant a left ventricular assist device (LVAD) as a bridge to transplantation for medical stabilization. Furthermore, the number of patients who have had at least one prior sternotomy while awaiting transplantation is increasing. Previous studies have indicated reoperative sternotomy as a risk factor for compromised survival. Concerns are specifically focused on perioperative, short-term, and long-term outcomes after LVAD explantation or redo sternotomy before OHT because of increasing operative complexity. We hypothesize that despite the greater technical difficulty caused by LVAD explantation or redo sternotomy, outcomes would not be compromised.
Methods:
We retrospectively analyzed patients who underwent OHT at the University of Pennsylvania during a 5-year period (2008-2013; n = 253). All patients who underwent a bridge to transplantation LVAD (n = 72) or prior sternotomy (n = 65) were compared with those undergoing OHT with a virgin chest (n = 116). Preoperative, intraoperative, and postoperative variables were analyzed. Short- and long-term survival were studied (minimum follow-up, 6 months).
Results:
Comorbidities were similar among the groups. There was no difference in donor allograft ischemic time (p = 0.6). However, cardiopulmonary bypass time was longer in both bridge to transplantation and prior sternotomy cohorts (p < 0.00001). The blood transfusion requirement was higher in bridge to transplantation (12.5 ± 13.7 units; p = 0.0007) and prior sternotomy groups (11.7 ± 12.9 units; p = 0.02) as compared with the virgin chest cohort (7.1 ± 10.7 units). For bridge to transplantation, both time to extubation (1.0 ± 1.6 versus 0.9 ± 1.0 days; p = 0.03) and intensive care unit length of stay (7.0 ± 7.0 versus 6.0 ± 7.0 days; p = 0.06) were longer compared with the virgin chest cohort. The same was true for prior sternotomy (extubation time, 1.9 ± 4.4 days; p = 0.005; intensive care unit length of stay, 8.0 ± 12.0 days; p = 0.06). There was no difference in hospital length of stay (p = 0.2). Overall, there was no difference in short- or long-term survival.
Conclusions:
Implantation of an LVAD as a bridge to transplantation or prior sternotomy does not adversely impact allograft function, hospital length of stay, or long-term outcomes after OHT. The decision to manage a patient medically while awaiting transplantation versus an LVAD bridge strategy should not be limited by concerns of subsequent poor outcomes after transplantation.
